What is the best pain medication for a pulled groin muscle (adductor strain)?

Best Pain Medication for Pulled Groin Muscle

For a pulled groin muscle (adductor strain), oral NSAIDs—specifically ibuprofen 400-600 mg every 4-6 hours—are the first-line pharmacologic treatment, with acetaminophen 1000 mg as an alternative if NSAIDs are contraindicated. 1

First-Line Pharmacologic Treatment

Oral NSAIDs are the preferred initial medication based on high-quality evidence from the American College of Physicians and American Academy of Family Physicians guidelines for acute musculoskeletal injuries. 1

• Ibuprofen 400 mg every 4-6 hours provides effective pain relief for acute soft tissue injuries, with a maximum daily dose of 3200 mg (though 2400 mg is typically sufficient). 2
• The evidence shows oral NSAIDs reduced pain by approximately 0.93 cm on a 10-cm visual analog scale at less than 2 hours, and 0.99 cm at 1-7 days compared to placebo (moderate-certainty evidence). 1
• Topical NSAIDs (applied 3-4 times daily) are an effective alternative with similar efficacy to oral NSAIDs but lower systemic side effects, reducing pain by 1.02 cm at less than 2 hours and 1.08 cm at 1-7 days. 1

Second-Line Option: Acetaminophen

If NSAIDs are contraindicated (due to gastrointestinal risk, renal disease, cardiovascular disease, or anticoagulation), use acetaminophen 1000 mg every 6 hours (maximum 4000 mg daily). 1

• Acetaminophen reduced pain by 1.03 cm at less than 2 hours and 1.07 cm at 1-7 days (moderate-certainty evidence). 1
• While effective, acetaminophen is generally less potent than NSAIDs for musculoskeletal pain. 3

Combination Therapy Considerations

Acetaminophen plus oral NSAIDs can be considered for severe pain, though evidence for this specific combination in groin strains is limited. 1

• The combination of acetaminophen 1000 mg plus ibuprofen showed no statistically significant additional benefit over single agents at less than 2 hours in the guideline evidence. 1
• However, alternating these medications (e.g., ibuprofen every 6 hours with acetaminophen in between) may provide more consistent pain coverage.

Medications to Avoid

Muscle relaxants (methocarbamol, cyclobenzaprine, carisoprodol) are NOT recommended for acute groin strains despite their common use. 4

• These drugs have no evidence of efficacy in chronic pain and questionable benefit in acute musculoskeletal injuries. 1, 4
• The combination of ibuprofen plus cyclobenzaprine showed no statistically significant pain reduction compared to placebo. 1
• Side effects including drowsiness, dizziness, and fall risk outweigh any potential benefits, particularly in older adults. 4

Opioids should be avoided for uncomplicated groin strains. 1

• While acetaminophen plus opioids showed modest pain reduction (0.50 cm at <2 hours, 1.71 cm at 1-7 days), the risks of dependence, side effects, and lack of functional improvement make them inappropriate for this indication. 1, 5
• Opioids do not address the underlying inflammatory process in muscle strains. 6

Practical Dosing Algorithm

1. Start with ibuprofen 400-600 mg every 4-6 hours with food (not to exceed 2400 mg daily for routine use). 2
2. If inadequate relief after 48 hours, increase to 800 mg every 6-8 hours (maximum 3200 mg daily). 2
3. If NSAIDs contraindicated, use acetaminophen 1000 mg every 6 hours (maximum 4000 mg daily). 1
4. Consider topical NSAIDs if oral NSAIDs cause gastrointestinal symptoms or in patients with multiple comorbidities. 1
5. Duration: Continue for 7-10 days or until pain significantly improves, then taper as tolerated. 1

Important Safety Considerations

Screen for NSAID contraindications before prescribing: 1

• Active or history of peptic ulcer disease or gastrointestinal bleeding
• Severe renal impairment (CrCl <30 mL/min)
• Heart failure or uncontrolled hypertension
• Concurrent anticoagulation (relative contraindication)
• Aspirin-sensitive asthma

For patients with GI risk factors, consider adding a proton pump inhibitor or using a COX-2 selective NSAID, though these are typically reserved for chronic conditions. 1

Monitor for acetaminophen hepatotoxicity risk factors: chronic alcohol use, pre-existing liver disease, or concurrent use of other acetaminophen-containing products. 1

Integration with Non-Pharmacologic Treatment

Medication should be combined with appropriate rehabilitation, not used in isolation. 6, 7

• Relative rest (avoid aggravating activities like kicking, sprinting, sudden direction changes) for 48-72 hours. 7
• Ice application for 15-20 minutes every 2-3 hours during the first 48 hours. 6
• Gradual stretching and strengthening of adductor muscles should begin once acute pain subsides (typically 3-5 days). 7, 8
• Physical therapy referral if pain persists beyond 2 weeks despite appropriate medication and rest. 7